PFD report

Esmee Shayla Polmear · Prevention of Future Deaths report

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Issued 27 May 2016•Cornwall and Isles of Scilly

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to recognise and act on paediatric respiratory red flag markers
    Part of recurring concern: Failure to reliably recognise respiratory distress in children
  2. Failure to routinely use oxygen blood monitoring in paediatric medicine
    Part of recurring concern: Failure to reliably recognise respiratory distress in childrenPart of recurring concern: Unreliable monitoring of oxygen saturation during clinical care
  3. Failure to routinely use respiratory rate benchmarks in paediatric respiratory medicine
    Part of recurring concern: Failure to reliably recognise respiratory distress in children
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to recognise and act on paediatric respiratory red flag markers

Wider context from the report

“At the inquest the Paediatric Expert, ████████ gave the opinion that • The routine use of respiratory rate bench-markers in paediatric respiratory medicine • The use of routine oxygen blood monitoring in paediatric medicine • The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise respiratory distress in children.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to routinely use oxygen blood monitoring in paediatric medicine

Wider context from the report

“At the inquest the Paediatric Expert, ████████ gave the opinion that • The routine use of respiratory rate bench-markers in paediatric respiratory medicine • The use of routine oxygen blood monitoring in paediatric medicine • The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise respiratory distress in children; Unreliable monitoring of oxygen saturation during clinical care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to routinely use respiratory rate benchmarks in paediatric respiratory medicine

Wider context from the report

“At the inquest the Paediatric Expert, ████████ gave the opinion that • The routine use of respiratory rate bench-markers in paediatric respiratory medicine • The use of routine oxygen blood monitoring in paediatric medicine • The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise respiratory distress in children.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026